Welcome to the 2014-2015 Academic Year! Emergency Lecture Series - Upper GI Bleed

Firstly, I just wanted to thank the outgoing CMR's for all of their hardwork and dedication over the past year.  I look forward to continued friendship and working with you guys into the future.

Now we shall get to business...

Our first blog today is about the Emergency Management of an Upper GI Bleed:

We discussed at lunch rounds today that there are 5 essential questions that need to be answered by the Internist in the emergency management of any patient with an upper GI bleed (UGI bleed).

Question #1:  Is this truly an upper GI bleed, or is it something else (hemoptysis, a lower GI bleed):

From the JAMA rational clinical exam series, useful historical features to help you answer this question include whether they've had a previous UGI bleed (LR+ of 6.2), if their is a history of melena (LR+ 5.5), cirrhosis (LR+ 3.1) and if they have been taking any anti-coagulation (mainly warfarin, but can likely be extrapolated to the NOAC's) - LR+2.3.

The most useful feature on physical exam to determine if the patient has an UGI bleed would be the presence of melena on DRE (LR+ 25).

Question #2: How severe is this UGI bleed?

Again, from the same paper, key historical features that predict a more severe UGI bleed include a history of malignancy or cirrhosis (LR + 3.7), and a history of syncope (LR+ 3.0).  On the physical exam, abnormal vital signs, mainly tachycardia (HR>100) has a (LR+4.9) for a severe UGI bleed.  The presence of an orthostatic drop in the blood pressure also is suggestive of a more severe UGI bleed (LR+ 2.8).

Luckily, in the 21st century a clinician does not have to memorize these numbers and they have been nicely integrated into a clinical score (Glasgow-Blatchford Score) - which can be accessed at the following link

http://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs/  .

Question #3: Does this patient have a variceal bleed?

To assist with answering this question from a clinical perspective, the JAMA series again proves useful.  Mainly, once you have determined the patient is having an UGI bleed, the next step is to search for signs suggestive of cirrhosis.  If any features of cirrhosis are present, then the safest approach would be to presume the bleed is variceal in origin.  Unfortunately in determining whether a patient has cirrhosis, history does not prove very useful.  The physical exam and baseline laboratory investigations are however, very useful.  The presence of distended abdominal veins "caput medusae" is particularly helpful in ruling in cirrhosis (LR+ 11).  Other helpful clues include encephalopathy (LR+10), ascites (LR+ 7.2) and jaundice (LR+ 3.8).

From a laboratory perspective, the most helpful clues to making a diagnosis of cirrhosis include thrombocytopenia (LR+ 9.8) if the platelets are less than 110, a prolonged INR (LR+ 5.0), and a low albumin (LR+ 4.4).

Again, if one suspects a variceal bleed, it should be treated as such.

Question #4: Does this patient need ICU or urgent endoscopy?

To answer this question, if there is hemodynamic compromise such as shock (elevated lactate, etc.) or signs of organ hypoperfusion (demand ischemia), the threshold for calling help is quite low.  For severe UGI bleeds (based on Glasgow-Blatchford score), or those with high risk features (hypotension, tachycardia), urgent endoscopy and close monitoring is essential.  If there is the suspicion of a variceal bleed, then ICU and GI should be notified in most cases immediately to help expedite endoscopy.

Question #5: Is the patient on an anticoagulant, and what is the indication?

This should essentially prompt the internist to consider the risks and benefits of reversing the anticoagulation.  These decisions are on a case-by-case basis and almost always should include input from gastroenterology, cardiology (in the case of mechanical valves), and hematology (in the cases of DVT/PE).  With the newer anti-coagulants, a phone call to the blood bank and ICU is also necessary as currently their exists no anti-dote or reversal agent on the market.

Those are the key questions to consider in the emergency management of an UGI bleed from the intern, or internist's perspective.  Please see the below references for further details on the management of an UGI bleed.

That was a long tangent... Welcome to 2014-2015

(Thanks Lee)

Management of Acute Bleeding from a Peptic Ulcer. Gralnek, et. al. NEJM. 2008

Does this patient have a severe Upper Gastrointestinal Bleed. Srygley, et. al. JAMA. 2012.

Does this patient with liver disease have cirrhosis. Udell, et. al. JAMA. 2012